title: Subspecialty training and surgical outcomes in children with failed bladder exstrophy closure.
abstract: OBJECTIVE
  Failure of initial and subsequent bladder closures has significant implications for patients with bladder exstrophy. We evaluated the association between outcomes of repeat bladder closure among patients who failed initial closure, and the credentials and training of the operating surgeons.
  
  
  METHODS
  From a bladder exstrophy database, we identified patients with a failed initial exstrophy repair. Records were evaluated with respect to success of the bladder closure (dehiscence or prolapse), number of closures required, surgeon credentials (fellowship-trained pediatric urologists (FPU) or other surgeons (OS)), post-closure bladder capacity, subsequent continence procedures, and continence outcomes.
  
  
  RESULTS
  Of 101 patients whose initial bladder closure failed, 94 patients underwent repeat bladder closure, of which 65 (69%) were successful. Of repeat closures performed by FPUs, 84% (54/64) were successful, while only 37% (10/28) of repeat closures performed by OSs were successful (P<0.0001). Of the 65 patients whose repeat bladder closure was successful, 38 (58%) achieved bladder capacity adequate for bladder neck reconstruction (BNR), versus only 10/29 (34%) patients whose repeat closure failed (P=0.032). Overall, after repeat closure, 26% were completely dry after BNR, 41% were partially dry after BNR, and 33% required further reconstruction for continence.
  
  
  CONCLUSIONS
  Among bladder exstrophy patients who fail their initial closure, repeat closure is more successful when the surgeon is a fellowship-trained pediatric urologist, and failure of repeat closure bodes ill for long-term continence. Exstrophy outcomes may be better at centers of excellence with significant experience in the management of this rare, complex condition.
authors.affiliation: Division of Pediatric Urology, Department of Urology, Riley Hospital for Children, Indianapolis, IN, USA.
authors.forename: Kirstan K
authors.initials: KK
authors.lastname: Meldrum
authors.forename: Ranjiv I
authors.initials: RI
authors.lastname: Mathews
authors.forename: Caleb P
authors.initials: CP
authors.lastname: Nelson
authors.forename: John P
authors.initials: JP
authors.lastname: Gearhart